The dyspepsia may end in a decided loss of tone and weakness of the muscular apparatus of the stomach. This is called atony, or motor insufficiency. The technical sign of the condition is the discovery that the stomach is unable to propel an ordinary meal into the bowels in the usual time. To definitely ascertain this fact, it is customary to give a test-meal in the middle of the day. It may consist of a plate of soup, five ounces of beef, two or three ounces of potato, a roll, and a glass of water. Under ordinary circumstances such a meal disappears from the stomach in five hours, leaving very few traces behind, and in seven hours at any rate the stomach would be quite empty. Therefore the amount of material which could be removed from the stomach five hours after the meal would be a measure of the loss of power or degree of atony of the stomach.

Atony of the stomach, or motor insufficiency, is one of the sequels of a long-continued indigestion, the causes of which have several times been enumerated. It should be stated, however, that there is a predisposition to this disorder in all persons who follow a sedentary occupation, who are subject to worry and the stress of business, to frequent losses of blood from any cause, prolonged discharges or the nursing of infants, anaemia, and other circumstances which interfere with the general nutrition. The condition often follows influenza, typhoid, rheumatic fever, and other febrile conditions. In most fevers there is a diminution of the ordinary activity of the stomach; the gastric juice is deficient, as well as motor power; and, although the appetite may return, the stomach does not always as quickly regain the power of digesting the food; consequently the atonic condition persists and may lead to serious trouble. It will be perceived, therefore, that this form of dyspepsia is not so often the result of errors in the food as those previously discussed, but it comes as the result of some previous illness and other circumstances which interfere with the general health.

Excepting when it follows a serious illness, atony of the stomach comes on slowly. The victim becomes pale and thin, has a worried and anxious expression, a look of weariness or fatigue; moreover, a sensation of weariness in the limbs and a dull pain in the head are often complained of. The gastric symptoms are not markedly different from those previously described in other dyspepsias. There is a feeling of weight and discomfort in the stomach, with heartburn, belching of wind, and rising of acid fluids. The acidity is caused by fermentation and bacterial decomposition. The products of decomposition of the food set up gastric catarrh, the gases originating therein distend the enfeebled organ and still further interfere with the motor functions, and lead to dilatation. When atony of the stomach has lasted for some time, the weakened organ nearly always becomes more or less dilated. The degree of dilatation is not very great at first, and, as the organ recovers tone and muscular power, the dilatation disappears. When dilatation occurs the pain and discomfort after eating are increased, food gradually accumulates in the stomach, and after a time the distension increases to such a degree that relief is only obtained by vomiting. In well-marked cases the vomiting occurs at intervals of two or three days, and the material brought up consists of the gastric secretion, semi-digested and fermented food, together with bacterial and fungoid organisms and their products. The influence of this dilatation and its interference with digestion is seen in the progressive emaciation of the body.

The diagnosis of dilatation, like that of failure of the motor power and gastric insufficiency, is made by drawing off the contents of the stomach after a test-meal. Apart from this test, the dilated organ can be felt by palpation and percussion of the abdomen. The stomach often extends below the umbilicus; and a sensation of "splashing" can be obtained by palpation. Moreover, the peculiar vomiting and the great amount of material brought up are only present in this disease. The quantity of material often amounts to two or three pints, or sometimes quarts; and it comes out of the mouth as if it were pumped up.

Thus we may see dilatation of the stomach resulting from a well-marked gastric irritation, but the organ regains its size when the stomach is empty; or from atony of the stomach, where the dilatation may be slight and depend on the recovery of muscular power; whereas in chronic gastric catarrh there may be dilatation varying from a slight degree, which disappears when the stomach is empty, to a more severe and permanent dilatation. But these functional disorders of the stomach are not the only causes of dilatation. It may occur as the result of an obstruction to the passage of food through the pylorus. Thus, it may be due to an ulcer in the duodenum or in the region of the pylorus, to a cancer or other new growth in the stomach or some adjacent organ, to adhesions, or traction upon the pyloric end of the stomach. In the obstructive form the dilatation of the stomach is not necessarily preceded by atony or loss of muscular power; as a matter of fact, the muscles of the stomach are normal, and, in the first instance, dilatation is prevented by a development of the muscles (hypertrophy) to overcome the obstruction. But by and by the muscle fails, it can no longer drive the food past the obstruction so well as it formerly did, and the stomach becomes dilated in proportion to the degree of failure. Thus, in pyloric obstruction there may be hypertrophy of the stomach without dilatation, hypertrophy with dilatation, or dilatation without hypertrophy. The dilatation is due to a distending force, but the distension does no harm to the stomach so long as the muscle is able to recover from stretching - that is, so long as the nutrition of the muscle is good. But when the nutrition fails, the stretched muscle remains stretched, and thus we have a secondary dilatation. In primary dilatation, due to atony or catarrh of the stomach, the muscle is already weak, and the resistance or elasticity which an ordinary muscle possesses is lost. In either case the distension is due to the delay of food in the stomach, to the deficiency of hydrochloric acid, the unchecked development of bacteria, and the fermentation and putrefaction which they cause. Thus arise the acids and gases which prolong the gastric irritation and catarrh, and intensify the dilatation by distending the stomach with gas.

Atony of the stomach, apart from dilatation, may be temporary or permanent. Atony which is the result of curable affections, such as infectious and other acute diseases, prolonged lactation, profuse discharges, haemorrhage, anaemia, chlorosis, overwork, worry, anxiety, and many other causes of indigestion, is curable. But that which occurs in Bright's disease, granular kidneys, amyloid disease, tuberculosis, malignant disease of various organs, and local affections in the stomach, such as prolonged gastric catarrh, atrophy of the mucous membrane, or cancer, is either incurable or only partially benefited by treatment.

Dilatation of the organ may also be of a temporary or permanent character. The slight degree of dilatation which occurs commonly in many cases of atony is curable. Still greater degrees of dilatation occurring as the result of duodenal or pyloric ulcer, and other forms of pyloric obstruction, may also be cured. But in those cases where the obstruction cannot be removed no cure can be expected.